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Key Points

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  1. Organoaxial volvulus is the most common reported type of gastric volvulus in childhood. Children do not reliably demonstrate the triad of Borchardt (unproductive retching, localized epigastric distension, and inability to pass a nasogastric tube). Associated diaphragmatic abnormalities should be assessed.

  2. Pyloric atresia (PA) is an extremely rare cause of intestinal obstruction and may occur in combination with epidermolysis bullosa.

  3. A completely obstructing antral web is treated with gastrotomy and circumferential web excision with oversewing of the mucosal remnant.

  4. The need for surgical therapy is dictated by the severity of microgastria. If drooling, reflux, or failure to thrive persists, gastric augmentation should be performed. The technical aspects of the procedure include creating a loop from the Roux-en-Y limb of the jejunum. This pouch is anastomosed to the side of the diminutive stomach.

  5. Most gastric duplication cysts can be bluntly dissected off adjacent organs. Dissection begins in the common muscular plane between the stomach and the duplication. The duplication is peeled off the mucosa of the stomach and removed.

  6. The most common type of gastric tumor in childhood is a teratoma.

  7. Recommendations for button battery removal from the stomach have changed. Typically, they pass on their own. Intervention is reserved for large batteries in small children (<6 years old) or if swallowed concomitantly with a magnet. Endoscopy is preferred but laparotomy and gastrotomy for removal may be necessary.

  8. Operative interventions should be considered for any persistently bleeding child with peptic ulcer disease. Some clinical indications for operative treatment are loss of 50% of the estimated blood volume in 8 hours, hemodynamic instability, and the presence of a visible vessel on endoscopy.

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The majority of gastric surgery in children is either gastrostomies or antireflux procedures. The surgeon managing infants and children must be additionally aware of the many gastric lesions that result in abdominal signs and symptoms. Most of these rare lesions cause either intrinsic or extrinsic obstruction of the stomach. Other lesions result in bleeding, perforation, or mass effect on the stomach.

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Obstructive Lesions

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Obstructive lesions of the stomach can be divided into those causing extrinsic obstruction (volvulus) or intrinsic obstruction (pyloric atresia [PA], antral web). The majority of these entities will be diagnosed in infancy. PA, however, will be diagnosed in the immediate newborn period. The common symptom of obstructive gastric lesions is nonbilious emesis. Each of these entities will be definitely diagnosed with gastrointestinal (GI) contrast studies. Following individualized surgical repairs, they have uniformly good outcomes.

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Gastric Volvulus

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Acute gastric volvulus is an uncommon surgical emergency in children. Chronic gastric volvulus is even rarer and can be very difficult to diagnose. Gastric volvulus results from an abnormal rotation of the stomach around 1 of 2 axes. Organoaxial rotation occurs about a line drawn through the gastroesophageal junction and the pylorus (Fig. 37-1A). The body of the stomach usually rotates back over the axis toward the lesser space. This is the most common reported type of volvulus in childhood. Mesentericoaxial volvulus occurs about an ...

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